Villages of Lonsdale.

Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected a resident when they failed to assess the resident’s skin. As a result, the resident acquired cellulitis (infection) of her leg, and a skin rash to her buttocks. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. A physician discovered the resident had cellulitis of her leg and provided an antibiotic medication. The facility administered the medication and evaluated her response to the medication. At the time, the resident lived in the assisted living area of the facility. Approximately, one month later, the resident became ill with Covid 19 then transferred into the memory care unit of the facility. The next morning, staff discovered redness of her buttock skin and provided medical care. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted a family member. The investigation included review of resident records, and employee files. Also, the investigator An equal opportunity employer. toured the facility and observed documentation systems, medication administration, the secured unit, and interactions between staff and residents. The resident resided in an assisted living facility in her own apartment but eventually transferred into the facility’s memory care unit. The resident’s diagnoses included dementia, anxiety, hypertension. The resident’s service plan included assistance with medications, meals, housekeeping, safety checks, and dressing. The resident’s nursing assessment indicated she walked independently and toileted herself. She required staff to remind and encourage her to do good hygiene. She was alert, but forgetful and confused. During an interview, a nurse said the resident sustained a small skin tear on her lower leg. She washed the area and applied a band-aid. The nurse said the resident was able to communicate her needs and did not complain of pain. The nurse said staff did not report any further concerns to her about the resident’s skin. The resident’s medical record indicated she went to see her physician approximately two weeks later. The records indicated her family brought her to the physician to evaluate her memory. During the exam, the physician observed the resident’s leg and noticed she had redness and swelling of her skin, but there were no open wounds. The physician diagnosed her with cellulitis and gave her an antibiotic medication. Progress notes indicated a nurse noticed the resident’s skin remained red after she completed the antibiotic medication and informed the physician. The physician gave the resident another antibiotic medication. Approximately one month later, resident became ill with Covid 19 and moved into memory care. The following day, the resident did not want to get out of bed, eat, or drink. The nurse observed the resident’s skin and noticed redness on her buttocks. The resident’s skin condition deteriorated. Her skin blistered and the redness spread to her legs. During an interview, the nurse manager said the resident became ill with Covid 19. During this time, a staff member told her the resident’s skin on her buttocks appeared red, so she went and looked at her skin. She told the staff to keep her skin dry and linins off her, but an hour later, the redness spread through her buttocks and leg. The manager said she called the resident’s family, then sent the resident to the hospital. The resident returned the same day. Hospital records indicated the resident had erysipelas (bacterial infection). They gave the resident antibiotic medications and returned her to the facility. During an interview, a family member said the resident recovered from her skin infections. The resident’s family moved her into a different facility. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: No, unable due to cognitive impairment. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable. he Action taken by facility: The facility coordinated medical care with the resident’s physician. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 07/15/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 26754 05/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 BIRCH STREET NORTHEAST VILLAGES OF LONSDALE LLC LONSDALE, MN 55046 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On May 15, 2024, the Minnesota Department of Health initiated an investigation of complaint #HL267549063C/#HL267541500M. No correction orders are issued. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 EGUX11 If continuation sheet 1 of 1

correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." In accordance with Minn. Stat. § 144G.31 Subd. 4, MDH may assess fines based on the level and scope of the vi ol ati ons ; however, no immediate fines are assessed for this srvey of your facility. DOCUMENTATIO ONF ACTION TO COMPLY In accorda nc e wi th Mi nn. Sta t. § 144G.30, Subd. 5(c), the licens ee mus t doc ument acti ons ta ken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area( s) of noncompliance was corrected related to the · resident( s)/ employee(s) identified in the correction order. Identify how the area( s) of noncompliance was corrected for all of the provider’s · resident( s)/ employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the · specific statute( s). An equal opportunity employer. Letter ID: IS7N REVISED 09/13/ 2021 Villages Of Lonsdale, LLC April 5, 2024 Page 2 CORRECTIO NORDER RECONSIDERATIO PNROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https: / / forms. web. health. state. mn. us/ form/ HRDAppealsForm The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/ or investigation process. Please fill out this anonymous provider feedback questionnaire at your conveni enc e at thi s link: https: / / forms. office.com/ g/ Bm5uQEpHVa. Your input is importa nt to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan. winkelmann@state. mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jodi Johnson, Supervisor State Evaluation Team Email: jodi.johnson@state. mn.us Telephone: 507-344-2730 Fax: 1-866-890-9290 PMB PRINTED: 04/ 05/ 2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 26754 03/ 06/ 2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 BIRCH STREET NORTHEAST VILLAGES OF LONSDALE LLC LONSDALE, MN 55046 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER LICENSING using federal software. Tag numbers have CORRECTION ORDER( S) been assigned to Minnesota State Statutes for Assisted Living License In accordance with Minnesota Statutes, section Providers. The assigned tag number 144G. 08 to 144G. 95, these correction orders are appears in the far left column entitled "ID issued pursuant to a survey. Prefix Tag." The state Statute number and the corresponding text of the state Statute Determination of whether violations are corrected out of compliance is listed in the requires compliance with all requirements "Summary Statement of Deficiencies" provided at the Statute number indicated below. column. This column also includes the When Minnesota Statute contains several items, findings which are in violation of the state failure to comply with any of the items will be requirement after the statement, "This considered lack of compliance. Minnesota requirement is not met as evidenced by." Following the surveyors' INITIAL COMMENTS: findings is the Time Period for Correction. SL26754016 PLEASE DISREGARD THE HEADING OF On March 4, 2024 through March 6, 2024, the THE FOURTH COLUMN WHICH survey at the above provider, and the following CORRECTION. " THIS APPLIES TO correction orders are issued. At the time of the FEDERAL DEFICIENCIES ONLY. THIS survey, there were 44 residents; 19 receiving WILL APPEAR ON EACH PAGE. services under the Assisted Living with Dementia Care license. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. The letter in the left column is used for tracking purposes and reflects the scope and level issued pursuant to 144G. 31 subd. 1, 2, and 3. 0 620 144G. 42 Subd. 6 (a) / 626. 557, Subd. 3 0 620 SS= D Compliance with requirements for reporting ma (a) The assisted living facility must comply with LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O1WQ11 If continuation sheet 1 of 27 PRINTED: 04/ 05/ 2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 26754 03/ 06/ 2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1000 BIRCH STREET NORTHEAST VILLAGES OF LONSDALE LLC LONSDALE, MN 55046 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 620 Continued From page 1 0 620 the requirements for the reporting of maltreatment of vulnerable adults in section 626. 557. The facility must establish and implement a written procedure to ensure that all cases of suspected maltreatment are reported. The requirement in Minnesota Statute section 626. 557, Subd. 3 is: (a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information to the common entry point. If an individual is a vulnerable adult solely because the individual is admitted to a facility, a mandated reporter is not required to report suspected maltreatment of the individual that occurred prior to admission, unless: (1) the individual was admitted to the facility from another facility and the reporter has reason to believe the vulnerable adult was maltreated in the previous facility; or (2) the reporter knows or has reason to believe that the individual is a vulnerable adult as defined in section 626. 5572, subdivision 21, paragraph (a) , clause (4). (b) A person not required to report under the provisions of this section may voluntarily report as described above. (c) Nothing in this section requires a report of known or suspected maltreatment, if the reporter knows or has reason to know that a report has been made to the common entry point. (d) Nothing in this section shall preclude a reporter from also reporting to a law enforcement agency. (e) A mandated reporter who knows or has STATE FORM 6899 O1WQ11 If continuation sheet 2 of 27 PRINTED: 04/ 05/ 2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B.